Provider Demographics
NPI:1043351018
Name:DESTINATION DENTAL PROFESSIONALS II
Entity Type:Organization
Organization Name:DESTINATION DENTAL PROFESSIONALS II
Other - Org Name:DBA/ DESTINATION DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST / OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:LATINOW
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:605-673-2011
Mailing Address - Street 1:141 N 5TH ST
Mailing Address - Street 2:
Mailing Address - City:CUSTER
Mailing Address - State:SD
Mailing Address - Zip Code:57730-1528
Mailing Address - Country:US
Mailing Address - Phone:605-673-2011
Mailing Address - Fax:
Practice Address - Street 1:141 N 5TH ST
Practice Address - Street 2:
Practice Address - City:CUSTER
Practice Address - State:SD
Practice Address - Zip Code:57730-1528
Practice Address - Country:US
Practice Address - Phone:605-673-2011
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-10
Last Update Date:2018-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDM-4901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty